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Transitional Care codes 99495 99496

Erin Posted Tue 19th of November, 2013 19:25:51 PM

Does a transitional care code '99495, 99496' (requirements met) billing provider have to be the provider who discharged the patient?

Can't find documentation that it does, but Cahaba Medicare rep told me our billing was invalid because the provider did not bill the discharge.

Please help.

SuperCoder Answered Tue 19th of November, 2013 20:25:19 PM

Hi,

Here is the excerpts from the coding institute article. Please have a go-

CMS has offered some fresh insights into how Medicare payers expect you to use 2013’s new transitional care management (TCM) codes.

CMS’s Ryan Howe alerted practices to the new information during the agency’s March 12 Open Door Forum, noting several important points about the TCM codes to keep in mind when completing your claims.

Refresh Your TCM Code Knowledge

The new TCM codes are:

· 99495, Transitional care management services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge, medical decision-making of at least moderate complexity during the service period, and face-to-face visit within 14 calendar days of discharge
· 99496, Transitional care management services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge, medical decision-making of high complexity during the service period, and face-to-face visit within seven calendar days of discharge.

The codes are intended to apply when a physician oversees a patient whose health issues necessitate moderate to high complexity medical decision making (MDM) during the shift from a healthcare facility setting back to the patient’s community (home) setting.

“A face-to-face visit is required within a specific time frame after the patient’s discharge, depending on which code you’re reporting,” said David A. Ellington, MD, an AMA CPT® Editorial Panel member who presented E/M changes at the CPT® and RBRVS 2013 Annual Symposium (www.ama-assn.org/resources/doc/cpt/04-e-and-m-ellington.pdf). “The initial interactive contact — face-to-face, phone call, or email — should be within two business days of discharge. If you make two attempts to contact the patient or caregiver within that time but are unsuccessful, CPT® states that you can still report transitional services if the other criteria are met.”

Example: AMA’s CPT® Changes 2013 includes a 99495 example in which “An 84-year-old female with hypertension and osteoarthritis is discharged from the hospital after a 1-week stay for congestive heart failure [CHF].” The example service involves a nurse care manager speaking with the patient’s family by phone the day after discharge to review medications and CHF self-management, and to make the follow-up appointment. The billing physician reviews the discharge summary and talks to consultants who treated the patient in the hospital. The next week, the patient presents for a face-to-face visit that includes prescription drug management, recommendations for diagnostic tests, and a home-health referral. The billing physician and clinical staff continue to monitor the patient’s weight during the 30-day TCM period via phone calls and home-health data feeds.

Reminder: “Some codes are mutually exclusive with the transitional care management codes, so you’ll have to look at CCI to look at additional services that may be bundled,” said Jim Bavoso of NGS Medicare during a Feb. 7, 2013, “Ask the Contractor” conference call.

Factor In These New FAQ Pointers

During the March 12 CMS forum, Howe emphasized the following areas:

· When determining which place of service (POS) code to use on your TCM claim, you should use the location that “required the face-to-face visit.”
· The 30-day TCM period begins on the date of discharge and continues for the next 29 days. Your date of service should be the thirtieth day of care — not the first, Howe said during the CMS call.
· CMS will reject any claims with dates of service prior to Jan. 30, 2013, because the codes became effective on Jan. 1 and only cover 30-day periods.
· You can report TCM codes for both new and established patients, Howe said, which is a departure from CPT® rules. “CPT® guidance suggests that the codes are only for established patients, but for Medicare purposes, they can be reported for new patients as well,” he said.
· If 30 days pass between discharge and the initial communication with the TCM practitioner, you cannot report TCM codes, Howe said during the call.
· Medicare will pay only the first TCM claim received per beneficiary in one 30-day period beginning on the date of discharge, so if more than one practitioner reports the code for the same patient, only the doctor whose claim is received first will get paid.
· If the patient dies before the thirtieth day of TCM, you cannot report the TCM codes because they cover a full 30 days. Instead, you’d report the appropriate E/M code.

For more on the TCM codes, read the FAQs at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-TCMS.pdf.

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